(list individual, facility, address, city, state, zip) (the “Requestor”). Additionally, I authorize SurgOne, P.C. to disclose the PHI via mail or facsimile. I expressly request that SurgOne, P.C. disclose full and complete PHI from the time period of:

I acknowledge that SurgOne, P.C. is may be able to receive remuneration in the amount (which will be determined at the time of processing by SurgOne, P.C.) for this disclosure. {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }

In addition to the authorization provisions above, I authorize the release and re-disclosure of all information, data, notes, records, reports, and all other documents to the Requestor, its consultants, experts, agents and/or other counsel relating to:

This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where alcohol/drug abuse information has been disclosed through records that are protected by federal law, or mental health records protected by state law, further disclosure is prohibited without specific written consent of the individual or as otherwise permitted by such law and/or regulations. A general authorization is not sufficient for these purposes.

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SIGNATURE INFORMATION:

I understand that this authorization may be revoked at any time, except to the extent already acted upon, by giving written notice to Requestor at the address listed above. I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned upon signing this authorization. I understand that the Requestor may redisclose this information, and if re-disclosed, the information would no longer be protected by federal privacy rules and regulations. Any facsimile or copy of this authorization authorizes the release of the records requested herein. {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }

(list individual, facility, address, city, state, zip) (the “Requestor”). Additionally, I authorize SurgOne, P.C. to disclose the PHI via mail or facsimile. I expressly request that SurgOne, P.C. disclose full and complete PHI from the time period of:

I acknowledge that SurgOne, P.C. is may be able to receive remuneration in the amount (which will be determined at the time of processing by SurgOne, P.C.) for this disclosure. {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }

In addition to the authorization provisions above, I authorize the release and re-disclosure of all information, data, notes, records, reports, and all other documents to the Requestor, its consultants, experts, agents and/or other counsel relating to:

This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where alcohol/drug abuse information has been disclosed through records that are protected by federal law, or mental health records protected by state law, further disclosure is prohibited without specific written consent of the individual or as otherwise permitted by such law and/or regulations. A general authorization is not sufficient for these purposes.

SIGNATURE INFORMATION:

I understand that this authorization may be revoked at any time, except to the extent already acted upon, by giving written notice to Requestor at the address listed above. I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned upon signing this authorization. I understand that the Requestor may redisclose this information, and if re-disclosed, the information would no longer be protected by federal privacy rules and regulations. Any facsimile or copy of this authorization authorizes the release of the records requested herein. {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }

(list individual, facility, address, city, state, zip) (the “Requestor”). Additionally, I authorize SurgOne, P.C. to disclose the PHI via mail or facsimile. I expressly request that SurgOne, P.C. disclose full and complete PHI from the time period of:

I acknowledge that SurgOne, P.C. is may be able to receive remuneration in the amount (which will be determined at the time of processing by SurgOne, P.C.) for this disclosure. {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }

In addition to the authorization provisions above, I authorize the release and re-disclosure of all information, data, notes, records, reports, and all other documents to the Requestor, its consultants, experts, agents and/or other counsel relating to:

This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where alcohol/drug abuse information has been disclosed through records that are protected by federal law, or mental health records protected by state law, further disclosure is prohibited without specific written consent of the individual or as otherwise permitted by such law and/or regulations. A general authorization is not sufficient for these purposes.

SIGNATURE INFORMATION:

I understand that this authorization may be revoked at any time, except to the extent already acted upon, by giving written notice to Requestor at the address listed above. I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned upon signing this authorization. I understand that the Requestor may redisclose this information, and if re-disclosed, the information would no longer be protected by federal privacy rules and regulations. Any facsimile or copy of this authorization authorizes the release of the records requested herein. {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }